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Template: Medical Intake
Travel and Relocation Health Assessment Form
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Assess the health of employees before travel or relocation for work purposes.
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Full Name
*
Date of Birth
*
Position/Job Title
*
Planned Travel/Relocation Destination
*
Expected Date of Departure
*
Expected Duration of Stay
*
Have you traveled internationally in the past year?
*
Yes
No
If yes, please list the countries visited
Do you have any existing health conditions that could be affected by travel?
*
Yes
No
If yes, please describe the conditions
Have you received all necessary immunizations for the destination?
*
Yes
No
Not Sure
Do you require any special medications or treatments during travel?
Any known allergies (e.g., food, medication, environmental)?
Additional health concerns or considerations for travel/relocation
Signature of Employee
*
Sign Here
Date of Submission
*
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